Transformative change

Dr. Jack Kitts, Chair, Health Council of Canada

We recently released Progress Report 2011: Health Care Renewal in Canada, a national look at progress being achieved in key areas of health care. As I discussed the report with the media, the subject of transformative change emerged as a key theme. But what is transformative change, and why is it important to talk about?

Transformative change relates to the service delivery model. We keep asking for more money, more doctors, and more nurses based on the status quo delivery model. But most health experts would agree that there’s probably enough money, human resources and capacity in the system already. If we were to change transformatively, we would be able to better deliver the service by maximizing the use of those resources. 

We need to ask important questions like: Is everyone working to their full scope of practice?; and Are we truly working in teams to the benefit of patients? There’s no question that with a change in interprofessional models of care and service delivery, with the tearing down of barriers and eliminating turf protection, we could deliver the service a lot more efficiently, with much higher quality.

Here’s the recipe for success:

1) Set ‘transformative change’ as a priority

2) Start with the federal government and get the collaboration of provinces and territories

3) Build information systems that allow you to measure progress

4) Set targets

5) Invest in achieving those targets

I believe that the publicly-funded system - with transformative change - can do a lot better in terms of health service delivery and cost. We need to allow the one system we have to carry on and strive for peak efficiency and service.

Key Words: Transformative change

Measuring Up: Do Health Care Systems in Canada offer High Quality Health Care?

Do we offer high quality health care? Despite this being a common question in primary health care offices, hospitals, provincial and territorial ministries of health and at a national level by politicians and the media – it’s a complex one to answer. 

To accurately evaluate the quality of health care, appropriate health indicators must be used, and results should be compared to valid standards or other appropriate benchmarks.  However, in order to take action on the results, quality plans need to be in place with strategic objectives.

Work has started at many levels within the health care systems to answer the “quality question”. The result has been an explosion of quality reports and health indicators used to create these reports, to the point that in some provinces hospitals, health care providers and administrators are overwhelmed with the amount of data that needs to be gathered and reported.    

Despite all of this activity, we are no closer to answering the “quality question”, particularly at the pan-Canadian level. Hospital or regional level indicators may not necessarily relate to provincial or pan-Canadian level indicators, making it difficult to interpret results at multiple levels in the health care system. 

We are currently exploring the various health indicators that are being reported on by public agencies in Canada to determine what is being measured why, and how these measurements are being reported. We will aim to answer the “quality question” at different levels within Canada’s federal, provincial and territorial health care systems. Look for our findings in a report to be released later this year.

Susan Brien, Policy Lead, Health Council of Canada

Fault Lines in the Health Care Bedrock

Guest blogger Pamela C. Fralick joined the Canadian Healthcare Association as President and CEO in February 2008. She also acts as co-chair of the Health Action Lobby, a coalition of 37 national health associations and organizations, co-Chair of Canadian Coalition for Public Health in the 21st Century, and Chair of the Quality Worklife-Quality Healthcare Collaborative. 

 
I’d like to begin at the end. This report concludes “...the next push lies in having all governments work together in the interests of all Canadians, which was the real promise of the Accords.”  And therein lies the rub... 

I was struck by my growing frustration as I read page after page of ‘optimism, but...’.  In other words, yes, there are advances being made, but the patchwork quilt of progress results in two major problems: 1) improved health outcomes as a result of the changes are still difficult to assess; and 2) the unevenly-applied changes across the country challenge a key value and condition on which our health system is based - universality.

Now back to the beginning for a few observations.

First, what bravery is (regrettably) required to embrace the transparency increasingly called for by that ‘rabble-rousing’ public!  But, in fact, the 2003 and 2004 commitment by the governments of Canada to report on their progress concerning significant health system reforms is likely unprecedented, and is to be commended.

Secondly, this Council report has done an excellent job of synthesizing an overwhelming amount of material, culled from multiple sources, into a plain-language, well-organized, user-friendly synopsis. It is anchored in evidence, and the reader who wishes more detail has the references to pursue.

Thirdly, and even more impressively, the report concludes we are actually making progress on many fronts, if not all, indicating that “in the seven years since the accords, almost every jurisdiction has made significant changes to the way they deliver health care”.

The review does, however, reveal two significant fault lines in what our 14 health systems are producing for Canadians:  1) we are not adequately measuring the impact of these system changes on health outcomes, and 2) a basic principle of the Canada Health Act, universality, is not being practiced consistently across the country.

The stated intent of the report was to assess improved access to care, the quality of that care, and health innovation. It has dealt thoroughly with available data and change regarding access, and equally so with innovation. However, and through no fault of its own, this report is simply not able to address the ‘quality’ question, with a few exceptions.

Despite calls for accountability, monitoring and evaluation, whether in the actual accords or in any of the many reports which have emerged following their signing, we are not there yet. For instance, comparability among provinces is still in its earliest stages, seven years on. Public information on wait times guarantees is not readily available, and data on its utilization is simply not known. Information from imaging centres is not readily available. The list continues.

So, while we can and should take modest pride in the strides accomplished, this Council report reveals we can’t simply ‘buy’ health. We can pick away at the edges of the system, and we can introduce isolated changes that collectively, may ‘do good’. We’ve identified and/or put many excellent ‘tools’ in place, from e-initiatives and emerging drug information systems to integrated services and improved role definition.  But we must also pose some very hard questions of each other, and our leaders:

·         What about the legislated entitlement of every Canadian to “the same level of health care”, wherever they live in Canada?

·         What about the right of the taxpayer to know that the changes his/her dollars are buying, are producing the health outcomes he/she expects for the investment?

·         When will all funders and influencers embrace a meaningful, collaborative approach to our efforts, ensuring the health of Canadians and the nation supersedes any jurisdictional or sectoral interests?

I look forward to a future Health Council of Canada report, when they will be able to connect the dots between health system changes and actual health outcomes, when comparable health services are available to all Canadians, regardless of where they live, and when targets and measures and accountabilities are commonplace.

Key Words: Health Indicators, Accountability

Meaningful Health Care Renewal: It’s All About the Information

Guest blogger Mike Barron is President and Chief Executive Officer of the Newfoundland and Labrador Centre for Health Information. He also serves on the Board of COACH, Canada’s Health Informatics Association, as well as the Newfoundland and Labrador Centre for Applied Health Research.

I am an unapologetic proponent of the health system use of information agenda. The premise of this “movement” is that the health system needs better information not only for improved direct patient care and safety but also for overall management of the broader integrated health system. For those of us who have been around, the sustainability and in essence the survival of our Canadian health system has been an issue for many years. It is through improved information availability at every level that we identify and understand the challenges as well as take advantage of opportunities to improve the health care system and population health in Canada. Most importantly for the purposes of this blog, it is through the health system use of information that the Health Council of Canada can provide key decision makers and the public with results of efforts to date in improving the health system in Canada.

So much for the soap box (not really).

The phrase “health care renewal” has become synonymous with significant changes and improvements that have been undertaken over the last number of years in the current health delivery and support system. The Health Council of Canada’s Progress Report 2011:Health Care Renewal in Canada  provides a broad overview/report card of recent significant health care renewal initiatives in this country and for the most part paints a positive picture on the results. That is good news for everyone in the country. The report also provides an indication as to how far we as a country still need to go to meet the current and future health system challenge. There is a lot of information in this report folks, but it is worth the read.

Both as a taxpayer and in my role as a health system leader, I am comforted and pleased with some of the progress that has been made as a result of the focused priorities and investments of our federal/provincial/territorial leaders. Investments in providing more timely provision of services and the required supporting infrastructure and infostructure are increasingly showing resultant value even in these formative years of health care renewal (yes, we are still at the very early stages even after all of these years).

In Newfoundland and Labrador, we are well along the path of electronic health record (EHR) development. We are currently one quarter of the way through integrating our community pharmacies with the provincial drug information system and we have already experienced many instances of improved patient safety. Our province-wide DI/PACS system and telehealth initiatives have both received positive post-implementation benefits evaluations. All the more reason why we need additional national investment in the EHR. The EHR journey is very much still in its early stages in this country and comprehensive availability and adoption at the jurisdictional level have not yet been achieved. However, with the joint investments to date of Canada Health Infoway and the jurisdictions, progress has generally been admirable.

One of the most refreshing and underlying messages of the report is the identified need for more and better information to support priority setting and to evaluate investment decisions. Given the disproportionate amount of provincial budget expenditure that the health system receives (now over 50% of total in some cases and costs continue to grow) it is necessary that we measure the impacts of introduced changes and investments in focused areas of delivery in order to either validate further investment or to avoid an escalation of commitment that yields little or no value. That is what successful businesses do and this is what the health system needs to do in order to carry out evidence-informed health care renewal.

This is why we need to design systems and processes that not only provide more direct value but also provide information that allows large investment decisions to be made that will result in the maximum value to the health system and, of course, the patient. Make no mistake, this information need is not predicated on saving money but on ensuring that the available money and resources are directed to areas that will maximize their utility.

The primary driver of health system costs are the expectations and demands of the general public. As the report notes, sometimes our indicators can be misleading, for example not everyone on the MRI waiting list necessarily needs an MRI. The report also indicates that teletriage services can be an effective means of helping people realize that alternatives to the emergency room exist. It is also noted that little evidence exists to its actual efficacy. Ontario is currently running advertisements aimed at helping people decide the most appropriate place for presenting with their primary health care needs. Is it working? I hope someone is evaluating this initiative and shares the results.

From a purely professional and personal perspective, I would like to see increased focus on funding that will enable the sharing and implementation of best practices for health care delivery across the country. We need to take advantage of good lessons learned. I would also be in favour of a national awareness campaign that hopefully begins to change public expectations of what they deem as quality health care. Many citizens still do not feel that they are getting good health care unless they get referred to a specialist, get a timely MRI, or walk out of the physician’s office with a prescription in their hand.

It all still comes down to having quality information.

Let us hope our federal/provincial/territorial representatives continue to get accurate and meaningful information that allows them to continue the value-push for improved health system performance at the micro and macro levels. As discussions begin related to a new national health accord of some form, let us hope this information allows them to make the right decisions on behalf of us all. I look forward to the Health Council’s next report.

Innovation Is the Key

Guest blogger, President and Chief Executive Officer of Canada Health Infoway, Richard C. Alvarez has been a catalyst for accelerating the development of electronic health records in Canada. He has established strong, collaborative relationships with the federal, provincial and territorial governments and other stakeholders as the foundation for solid progress. He has articulated a broad national vision for reforming Canada's health care system through innovation and technology. On the international front, he has helped to position Canada as a world leader in health care renewal.

I read with great interest the Health Council of Canada’s Progress Report 2011: Health Care Renewal in Canada.  For those areas under the microscope in this year’s report, namely Wait Times, Pharmaceuticals Management, Electronic Health Records, Teletriage and Health Innovation, the Health Council deemed that progress has been made in comparison to the last time they reported on these areas.  In concluding its report, the Council urged governments and others to set targets and goals so that it would be easier for all, especially for Canadians, to judge the pace of progress in future years.  They so rightly summarized that in health renewal “money is the fuel” while “management gets the traction.” 

In the area of Electronic Health Records, the Board of Canada Health Infoway, in consultation with its members, decided on a “call to action” by aiming to have health records electronically available for 50% of Canadians by 2010.  As was reported by the Council, through the dedicated efforts of our jurisdictional partners, we came preciously close to achieving that goal at the end of 2010. 

And while we have a way to go to achieving the vision of a modernized health care system enabled by IT, already we are receiving some major benefits.

A little while ago, we established a benefits evaluation framework – the first of its kind – on the premise that “you can’t manage what you can’t measure.” Some of the benefits as they relate to pharmaceuticals management are listed in the report, but we are also seeing benefits valued at millions of dollars in the areas of diagnostic imaging and telehealth.

Looking at diagnostic imaging, more than 95% of the most common radiology examinations and reports in Canada’s acute care hospitals are now digital, up from approximately 38% only six years ago. When diagnostic imaging and Picture Archiving and Communications Systems (PACS) are fully implemented in Canada, they are expected to generate benefits valued at between $850 million and $1 billion per year.

And on the telehealth front, by the end of the 2009–2010 fiscal year, Canada had in place 5,710 telehealth systems in 1,175 communities.  Telehealth events saved Canadians living in rural or remote communities an estimated 46,846,500 kilometres of travel in 2010. This not only means travel distance saved, but also $70 million in personal travel costs, 5.6 million litres of gasoline and almost 13 million kilograms of CO₂ emissions avoided – the equivalent of removing 2,760 cars off the road.  

That said, there is more work to do. The Council rightly draws attention to the 2009 Commonwealth Fund International Survey which places us at the back of the bus among 11 countries, with only 37% of physicians using electronic medical records (EMRs) in primary care.  To address this gap, much of the last $500 million that Infoway received from the federal government has been devoted to seeking clinical value through the use of EMRs in primary care and ambulatory care settings. Key to these efforts is a renewed emphasis on clinician engagement. Beyond primary care, our country tends to perform better relative to its peers. For example, Canada is a global leader in the use of telehealth and compared to other OECD countries has one of the most comprehensive sets of health policy data. Nevertheless, there are opportunities for further progress in areas such a telepathology, telehomecare, and privacy-sensitive health system use of information.  

It is interesting to note that the Council chose to report on “Health Innovation” as part of its 2011 Report.  At Canada Health Infoway, we believe “innovation” is key to the sustainability of our health care system, which is why, this year, we launched a new innovation strategy.. Our clinical reference groups helped us identify focus areas for clinical innovation investments; focus groups and surveys of the public helped to narrow the priorities for our consumer health investments.

Finally, the Council urges government to accelerate the general health system goals of improved patient care, co-ordination of care, reduced errors, and improved efficiencies.  Effective use of information and communications technologies (ICT) is an enabler for progress in many areas, from patient safety to improving access to care. We look forward to working with partners from across the country to encourage the innovation that will make this possible. That’s why we recently launched a public ImagineNation challenge, asking for the best ideas to improve health and health care using ICT. I would encourage you to help us to accelerate the pace of change by reviewing the ideas that came in and voting for the ones that you think are most promising.  Where do you think there exist opportunities to invest in additional innovations in health care in Canada? 

Key Words: Innovative Practices, Electronic Health Records

The Patient's Perspective

Guest blogger Joyce Resin is the Executive Director, Community Action at ImpactBC, an organization that works with BC patients, providers, and policy makers towards quality improvement in health care. Joyce oversees the Patient Voices Network, a registry of over 1000 British Columbians who apply their experience and voice to partner for change within the health care system. The Patient Voices Network is an initiative of ImpactBC in collaboration with Patients as Partners, British Columbia Ministry of Health.

Every organization should be dedicated to continuous quality improvement, but few areas are as scrutinized as the health care sector. Shifting demographics, emerging research findings, and resource allocation are just a few factors that require administrators and front-line staff to continuously look for ways to increase efficiency and improve outcomes.

Fortunately, there is innovation and leadership in the sector that make this a really exciting time to be working in health care. Change no longer happens from the top down – it is informed by a number of common themes that I’m pleased to see in the Health Council of Canada’s recent Progress Report 2011: Health Care Renewal in Canada. The council clearly understands that true change comes from the following:

An evidence-based approach
Throughout the examples in the report we see attention to methodology, robust and careful reporting, and the use of benchmarks and clearly articulated targets. The correct path to quality improvement sometimes seems obvious, but it often requires careful thinking and experimentation. It’s only through analysis and measurement that we can articulate our goals and be sure we’ve reached them.

Collaboration
Whether it’s consolidating records online or assembling a cross-jurisdictional collaborative, there’s value in bringing people and resources together. Time and money are wasted in silos, and information moves as quickly as change does. By streamlining our efforts and finding structured ways to share our resources, we reach our targets faster.

Use of technology
The age of technology is upon us, across all regions and demographics. It’s a valuable tool for collaboration and improving access to information, and it’s exciting to see so many examples of effective teletriage, as well as online tracking and records management.

One of the most important themes in health care improvement – throughout this report and throughout our country – is the patient centred approach. The patient is the expert in his/her own life, and the only person who experiences every aspect of care. Putting the patient first means looking carefully at issues such as wait times and access to information and resources. In some sections the report talks about the patient’s “journey” – a way of looking at the system holistically through the eyes of the user, in order to find gaps or duplications in care.

Patient-centric also means integrating the patient voice into the process of change. At ImpactBC, through the Patient Voices Network, we work to make patients partners in improvement, giving them the skills they need to participate in change and linking them with opportunities to work with policy makers.

“Everyone benefits from a patient-centric approach,” says Sheila Allison, a Patient Voices Network member. “Patients are heard, and are treated as partners in the change process. Physicians tell me that the patient voice changes their perspective and reminds them why they are there. Historically, change happened slowly and in isolation, but I truly believe we’re in the midst of a paradigm shift.”

It’s clear that the Health Council of Canada is part of this shift – they have recruited patients for consultation in their reporting and as seen in the Progress Report, they aim for a high level of literacy and accessibility.

It’s wonderful to see innovative approaches to improvement taking a foothold all across Canada. The results speak for themselves both in numbers and in patient experience. Congratulations to the Health Council of Canada on some excellent successes to date – and some exciting groundwork for moving forward.